The Opening Line that Predicts Anti-Cannabis Outcomes in Clinical Studies

For generations, government-installed hurdles limited cannabis research to harm studies, leaving the scientific community with such epic fails as, "It is often harder to get people who aredependent on cannabis through withdrawal than for heroin" and "Prostitutes use cannabis… [and] this may be another symptom of their defective personalities." Arcane restrictions still exist, but cannabis studies are increasing in quality and quantity, just as potential anti-cannabis bias has become easier to identify.

One such sign of potential bias is a commonly repeated line that appears at the start of many clinical studies. Notice the recurring theme that appears in the first line of the following studies:

International Addiction Review (2019): Cannabis remains the most illicit drug used in the world today with an estimated 147 million people using cannabis regularly.

The Lancet (2009): Cannabis, commonly known as marijuana, has been the most widely used illicit drug by young people.

Australian Dental Journal (2008): Cannabis, commonly known as marijuana, is the most frequently used illicit drug in Australia.

The Lancet (1998): Cannabis is the most widely used illicit drug in many developed societies.

All of these studies start by calling cannabis the world's most-used illicit drug and conclude that cannabis is harmful. PRØHBTD examined hundreds of clinical studies that led with a variation of this line, and the only exception to this trend stated that the findings were inconclusive.

Why is this language so prevalent in anti-cannabis studies? We contacted the researchers behind the studies listed above to find out, and while only two replied, the first response offers some insight.

"That first line in most research on cannabis informed the work," said Dr. Nosarieme Abey, who authored the Food and Chemical Toxicology study (and other research that utilized the same loaded language). "It is somewhat serving as the problem statement, which in that paper I sought to understand some of the underlying mechanisms of action and consequences."

The intent of the line is to describe how big the cannabis "problem" is, the researcher suggests, but that presupposes that most cannabis use is inherently problematic.

Dr. Gene-Jack Wang, a clinical director at the National Institute on Alcohol Abuse and Alcoholism, co-authored the study that appeared in the Journal of Neuroimmune Pharmacology. Responding to our query, he stated, "The sentence is based on a most recently published review article from School of Public Health, Columbia University and NYSPI. It is one of the most well-known institutes on substance use disorder."

Dr. Wang references a 2017 study that states cannabis legalization (medical or recreational) "may increase cannabis-related adverse health and psychosocial consequences," and you should be able to guess what language appears in the opening line. Still, that wasn't our question.

When we asked again why that opening line is so widespread, Dr. Wang ignored the question and dove right into the potential dangers of cannabis.

"Many states in [the] U.S. plan to legalize cannabis use beyond medicinal purpose," he responded. "Many cannabis users assume the medical consequences of cannabis use are less harmful compared to other substances. Our recent original publications showed long term cannabis use would affect brain function as we cited in the review article. This review article evaluated cannabis use through the neurobiological model of addiction to summarize our prior imaging studies."

A Seattle-based neuroscientist who studies medical cannabis agrees that these opening lines are problem statements, but he sees the use of this language as problematic itself.

"I think that particular line is low-hanging fruit when it comes describing the negative consequences of cannabis use," Dr. Joshua Kaplan explained. "You often don't see this line in articles describing its benefits, but most articles describing the negative effects of drugs often start by describing their prevalence. The statement is generally accurate, but only because the global community, heavily influenced by the United States, has made the cultivation and use of cannabis illegal. So the line in question is not a requirement, per se, but an easy way to frame the significance of the problem being described in the paper."

Still, the problem statement is not entirely accurate. Dr. Kaplan continues, "In some states in the U.S., this statement is inaccurate since it's not illicit. The most widely used drug award goes to caffeine, although some have suggested that aspirin is more widely used."

Fighting for Truth on an Uneven Playing Field

Another researcher, who asked to remain anonymous, believes the use of the oft-repeated line may also be a political calculation for those seeking research funding or access to federal cannabis supplies.

"I think that it is boilerplate language expected of anyone who wants to remain competitive for [National Institute on Drug Abuse] funding," said the researcher, "though I don't know if you'll get any researchers to admit to it. We submitted a grant to NIDA—including a well-respected substance-use researcher and medical anthropologist—to use the [state] medical cannabis patient registry to investigate why people with PTSD [post-traumatic stress disorder] enroll in the program. It was panned, and the major criticism was that we didn't sound as though we had aimed the study at showing that cannabis was bad for PTSD."

Dr. Donald Abrams, famous for his studies on cannabis and the HIV virus, experienced this type of problem in his dealings with NIDA, who must approve the use of cannabis for clinical studies. He sought to research potential medical uses, and he eventually pressed NIDA about its continued resistance. Speaking with PRØHBTD, he confirmed their response as follows: "I need to remind you, Dr. Abrams, that this is the National Institute on Drug Abuse and not the National Institute for Drug Abuse."

In 2006, the Boston Globe characterized the problem this way: "It's not in NIDA's job description—or even, perhaps, in NIDA's interests—to grow a world-class marijuana crop. The institute's director, Nora Volkow, has stressed that it's 'not NIDA's mission to study the medicinal use of marijuana or to advocate for the establishment of facilities to support this research.' Since NIDA's stated mission 'is to lead the Nation in bringing the power of science to bear on drug abuse and addiction,' federally supported marijuana research will logically tilt toward the potential harms, not benefits, of cannabis."

PRØHBTD reached out to NIDA for comment and requested access to Dr. Volkow, who co-authored the Preventive Medicine study with Dr. Wang. NIDA did not give us access to its director, though a representative responded to our query about the possible connection between "problem" statements and funding: "The National Institutes of Health, including NIDA, does not provide or encourage any specific language in grant applications. Applications are considered based on scientific merit and robust study design, and are reviewed by independent scientific experts."

NIDA's Evolution on Cannabis

The Nixon Administration established NIDA in 1974, and the president's thoughts on cannabis have been preserved on tape. "I want a goddamn strong statement on marijuana," said Nixon in 1972, seeking to justify the Schedule I prohibition of cannabis. "Can I get that out of this sonofabitching domestic council?… I mean one on marijuana that just tears the ass out of them."

Nixon's frustration centered on a Republican-led council that was meant to validate cannabis prohibition but ultimately recommended decriminalization. NIDA, on the other hand, gave a succession of Drug War presidents all the goddamn ass-tearing statements they could use.

While founding NIDA director Robert L. DuPont originally broke with the president byrecommending the liberalization of cannabis laws, he later acquiesced andcalled cannabis the "most dangerous drug" in the world. His replacement, Dr. William Pollin,called cannabis "a major public health menace" with "potentially very grave consequences for… the nation's future," while Alan Leshner (the director during Dr. Abrams' HIV studies) resisted the medical cannabis movement withdismissive lines like, "The plural of anecdote is not evidence." Dr. Glen Hanson, the fourth director, stillrails against the legalization movement, saying, "I have a hard time not laughing when they say, ‘It’s no worse than alcohol and tobacco!’ My response: Did you know tobacco kills 400,000 people every year in a way that is so agonizing and horrific, and that it costs $200 billion a year to treat? Did you know alcohol kills 100,000 a year and costs $200 billion?"

Dr. Hanson, who mindlessly attributed the exact same cost to tobacco and alcohol use, must've also missed the NIDA statement that said there are "no reports of teens or adults dying from marijuana alone."

Coincidentally, that last statement about no reported deaths came under NIDA's current director, Dr. Volkow, who assumed the role in 2003. The Mexican-born researcher still takes a conservative approach to cannabis, but she's gradually moved the needle in recent years and became the first director to officially recognize its medical benefits. In 2015, the NIDA website created a page titled "Is Marijuana Medicine?" and then changed it to the more definitive "Marijuana as Medicine" in 2017. NIDA also described cannabidiol (CBD) as "a safe drug with no addictive effects… [that] may have therapeutic value for a number of medical conditions," and it's now funding more robust research that includes a 2019 study on cannabinoid receptors and an upcoming study on cannabis and pain.

In other positive news, the Senate Appropriations Committee released a 2018 report titled "Barriers to Research" that stated, "The Committee is concerned that restrictions associated with Schedule I of the Controlled Substance Act effectively limit the amount and type of research that can be conducted on certain Schedule I drugs, especially marijuana…. We should be lowering regulatory and other barriers to conducting this research." The committee then directed NIDA to provide a report on how to do just that.

Progress is also evident on an international level. Per media reports, the World Health Organization (WHO) finally acknowledged the medical benefits of cannabis and recommended a major rescheduling under its international treaties. This would give countries more control over their cannabis laws and potentially lead to global changes in cannabis access. The European Parliament also voted last month to advance a non-binding resolution to address the current restrictions on medical cannabis research.

These changes are modest and long overdue, and they should be viewed as first steps in a necessary journey that still has a long way to go. Nevertheless, the changes represent significant gains against the institutionalized prohibition that's existed for decades at the highest levels of government.

To understand just how much of an institution prohibition had become, consider some of the quotes we already presented above. The line about cannabis and prostitutes in our opening paragraph came from the United Nations Office on Drugs and Crime (UNODC). The argument that joints can be harder to give up than heroin needles came from Dr. Wayne Hall, the Director of the Centre for Youth Substance Abuse Research and the former Director of the National Drug and Alcohol Research Centre in Australia. The founding NIDA director argued that cannabis is more dangerous than heroin and crack. These outrageous claims come from high-ranking officials, whose titles give credibility to what should otherwise be considered crackpot ideas.

Conversely, officials who spoke out against prohibition in the past often faced backlash. Dr. David Nutt served in several government health roles in England and spent two years with NIDA as a visiting scientist. However, when Dr. Nutt published "a rational scale" of drug risk that ranked alcohol and tobacco as more dangerous than cannabis and other recreational drugs, the British government sacked him and the press labeled him"the Nutty Professor."

Law enforcement, health officials and bureaucrats helped institutionalize anti-cannabis bias, but as the tide slowly turns against prohibition, the public is increasingly better equipped to recognize potential bias and dismiss bullshit propaganda. An understanding of what drives a "most-used illicit drug" line provides yet another tool in the fight to elevate unbiased cannabis research.

All this leads us to a 2018 editorial (not a study) inScientific American that used the oft-repeated line with a very different conclusion. The article opened with, "Cannabis—marijuana—is the world's most commonly used illicit drug," and concluded, "It is time to stop treating marijuana like a deadly drug, when science and public opinion agree that it is relatively safe for adult recreational use."